This is a great paper about “prescribing inertia,” which is the tendency for medications, once prescribed, to be continued indefinitely even when this is not good medical practice. The easiest example that comes to mind is PPIs, like omeprazole. Once a patient gets started on a PPI, it tends to be continued forever. Other examples, however, are NSAIDS, anti-depressants and chronic benzodiazepines. If the clinical indication for a medication has passed, the patient cannot get any benefit from the drug but still is susceptible to all of the medication’s side effects.

Let me give two examples that I am personally acquainted with. A friend of mine began to take high dose Naproxen due to a minor athletic injury. When the injury healed, he continued to take Naproxen every night before bed even though he did not hurt any more simply because it was his habit and because (as he put it) “Maybe I’ll wake up with pain during the night.” Unfortunately, what he woke up with one morning was projectile vomiting of bright red blood from his NSAID-induced ulcer.

Another friend was started on blood pressure medications when he was overweight and out of shape. Year or so later, he became quite fit and lost a substantial amount of weight. However, nobody thought to see if he still needed antihypertensive drugs—despite the fact that every single blood pressure he had over the next four years was normal, and I mean like 108/66 normal. Hypertension, of course, like Type 2 diabetes, is part of the “metabolic syndrome,” and often will improve or even go away entirely if patients lose weight. This particular guy competes in Triathlons, for heaven’s sake! So, his doctor finally stopped his blood pressure meds and–who’d a thunk it?—his blood pressures remained normal.

I see this frequently in my jails. Patients come to jail taking medications that they clearly don’t need (in my opinion). Doxycycline for invisible acne. Metformin for patients without Type 2 diabetes (or even insulin resistance). Two different SSRIs in the same patient.

According to this weeks interesting article, the main obstacle to stopping unnecessary medications is the patient’s perception that taking these medications is the standard of care and that stopping them is substandard care. “My doctor thinks I need this,” they will say.

I agree. In order to effectively stop unnecessary medications, you need to have patient buy-in. In my experience, the easiest way in correctional medicine to get patient buy-in is to call the patient’s outside physician, explain what medication changes you want to make, and ask if that is OK. Almost always, the outside physician will agree. Then you can approach the patient by saying, “I’ve been talking to your doctor and we both think we should make some changes in your medications. Here are the changes and here is why we are doing it (with the emphasis on we).” (see The Right Way to Deal with Outside Physicians).

There actually is a term for this process. It is called “Medication Reconciliation” and is a term invented by JCAHO, which accredits hospitals. JCAHO requires all hospitals to do a “Medication Reconciliation” for each and every patient being discharged from that hospital. Even ER patients!

The process of Medication Reconciliation in hospitals involves going over each patient’s personal medication list, plus any new medications prescribed at the hospital, looking for unnecessary medications, unnecessary polypharmacy, drug interactions, etc. Often in the hospital, this is done with the aid of a clinical pharmacist.

I think “Medication Reconciliation” is a great term and a great idea that we should adopt in Correctional Medicine. But instead of doing our “Medication Reconciliation” when patients are discharged from our facilities, we should do it when patients come into the facility. Input from a clinical pharmacist, especially for complicated cases or long drug lists, would be especially helpful.

Do you have any good stories about “Medication Reconciliation” at your facility? Please comment!

One aspect I would recommend as a part of ‘medication reconciliation is medication verification. We contact the pharmacy on every inmate who reports medication use – to determine compliance and often discover unreported (or erroneously reported) medications. It does take time (and compliance of the health care staff) but it provides a great basis for making determinations on what medication to continue (or not).
Nurses can implement any maintenance medication (HTN, DM, Seizure, etc.) when the inmate is clearly current / compliant. They call jail provider to consult on: non-compliant, controlled, mental health medications; or when a start, stop, modification order is indicated (start=HTN and non-compliant; stop=three different benzodiazepines; modify=dose adjustment to fit med pass times).
The verification forms are reviewed and signed by the jail provider on the next clinic day.
Happy to share our form and provide any information/

Well stated, Al. An essential part of medication reconciliation is verifying that drugs are appropriately prescribed and that the patient has been compliant! I have seen patients non-compliant with hypertension medications–but whose blood pressure was normal!

Just to take this discussion a bit further in Canadian Federal Penitentiaries the Registered Nurses do a medication reconciliation (and a medication verification) on every inmate that is transferred in, being transferred through, or a new admission as well as a medication reconciliation on every offender being transferred, or being released (and linking them with a local pharmacy). It is very tedious work but I would say that medication reconciliation process when done correctly eliminates about 1/5 of medications either being prescribed, incorrectly correctly continued, or dispensed upon release or transfer.

Thanks for the comment Holly. I agree, medication verification and reconciliation can be tedious work. It constitutes a big fraction of what the jail nurses do every day. But it is necessary to do it to practice the best medicine. I also agree that at least 1/5th of the medications brought to the jail are inappropriate in one way or another. The whole process of medication verification deserves a blog post of its own! Keep up the good work!

Great discussion and replies. However, medication review while extremely important on intake and discharge is best served on a continuous process. Also include AI software or pre-approved hot lists (common duplications, contraindications, etc.) or your clinical pharmacist if your facility employs them.

Your email address will not be published. Required fields are marked *

Comment

Name *

Email *

Website

Save my name, email, and website in this browser for the next time I comment.

Notify me of follow-up comments by email.

Notify me of new posts by email.

Jeffrey Keller

About

Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of emergency medicine practice experience before moving full time into his “true calling” of Correctional Medicine. He is the Medical Director of Badger Medical, which provides medical services to several jails and juvenile facilities in Idaho. Dr. Keller is available for consultation on any aspect of Correctional Medicine, including legal cases, program development, and system analysis.

Expert Consultation in Correctional Medicine

Dr. Keller is available for consultation on any aspect of Correctional Medicine, including legal cases, program development, and system analysis. Dr. Keller has wide experience in both jail and prison systems and in both clinical practice and administration. Read more

Join the American College of Correctional Physicians!

The American College of Correctional Physicians is the professional organization for correctional practitioners. ACCP needs you! ACCP provides these services: